SCIENTIFIC ARTICLE

Clinical Applications of Perforator-Based Propeller

Flaps in Upper Limb Soft Tissue Reconstruction
Shimpei Ono, MD, PhD, Sandeep J. Sebastin, MD, Naoya Yazaki, MD, PhD, Hiko Hyakusoku, MD, PhD,
Kevin C. Chung, MD, MS

Purpose A propeller flap is an island flap that moves from one orientation to another by
rotating around its vascular axis. The vascular axis is stationary, and flap movement is
achieved by revolving on this axis. Early propeller flaps relied on a thick, subcutaneous
pedicle to maintain vascularity, and this limited the flap rotation to 90°. With increasing
awareness of the location and the vascular territory perfused by cutaneous perforators, it is
now possible to design propeller flaps based on a single perforator, so-called “perforator-
based propeller flaps.” These flaps permit flap rotation up to 180°. We present the results of
upper limb soft tissue reconstruction using perforator-based propeller flaps. We constructed
a treatment strategy based on the location of the soft tissue defect and the perforator anatomy
for expedient wound coverage in 1 stage.
Methods All perforator-based propeller flaps derived from 3 institutions that were used for
upper limb soft tissue reconstruction were retrospectively analyzed. The parameters studied
included the size and location of the defect, the perforator that was used, the size and shape
of the flap, the direction (ie, clockwise or counter-clockwise) of flap rotation, the degree of
twisting of the perforator, the management of the donor site (ie, linear closure or skin
grafting), and flap survival (recorded as the percentage of the flap area that survived).
Results Twelve perforator-based propeller flaps were used to reconstruct upper limb soft
tissue defects in 12 patients. Six different perforators were used as vascular pedicles. The
donor defects of 11 flaps could be closed primarily. One flap was partially lost in a patient
with electrical burns.
Conclusions Perforator-based propeller flaps provide a reliable option for covering small- to
medium-size upper limb soft tissue defects. (J Hand Surg 2011;36A:853–863. Copyright
© 2011 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Perforator flap, propeller flap, reconstruction, soft tissue defect, upper limb.

PERFORATOR FLAP is a type of vascular flap based The main advantage of a perforator flap is that it does

A on one or more cutaneous perforators of an

underlying vessel, and flap movement is
achieved by mobilization of the cutaneous perforator.
From the Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo,
Japan;DepartmentofHandandReconstructiveMicrosurgery,NationalUniversityHealthSystem,Singa-
pore; Department of Orthopaedic Surgery, Nagoya Ekisaikai Hospital, Nagoya, Japan; Department of
Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan; Department of Sur-
gery, The University of Michigan Health System, Ann Arbor, MI.
Received for publication August 17, 2010; accepted in revised form December 16, 2010.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
not need division of the underlying main vessel. How-
ever, dissection of the perforator can be difficult, espe-
cially if the course is intra-muscular. In addition, move-
Supported in part by a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120)
from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (K.C.C.).
Corresponding author: Kevin C. Chung, MD, MS, Section of Plastic Surgery, University of Michigan
HealthSystem,2130TaubmanCenter,SPC5340,1500E.MedicalCenterDrive,AnnArbor,MI,48109-
5340; e-mail: kecchung@umich.edu.
0363-5023/11/36A05-0015$36.00/0
doi:10.1016/j.jhsa.2010.12.021

©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 853

854 PERFORATOR-BASED PROPELLER FLAPS

FIGURE 1: Movement and design of a perforator-based propeller flap. ADBC, defect; X, location of dominant perforator; XB,
XB=, length of flap required; CD, C=D=, width of flap required; A=C= B=D=, flap design; XD=A=C=, bridge segment of flap.
Location of vascular pedicle (X) remains constant after flap transfer, and the bridge segment of flap helps in closure of the donor
defect.

ment of the flap is limited by the length of the
perforator, thus restricting its use for adjacent defects. A
propeller flap is an island flap in which flap movement
is achieved by rotation around its vascular axis.1–3 The
vascular axis itself is stationary, and flap movement
occurs by rotating on this axis (Fig. 1). It has been so
named because it is like a propeller in which the blades
rotate around a fixed axis.1 The donor defect of a
propeller flap can be closed linearly, if the surrounding
skin is lax, with skin grafting, or by designing the flap
with 1 or 2 additional lobes (similar to a bilobed flap).4
Early propeller flaps were not based on any specific
vessel and relied on a thick, subcutaneous pedicle to
maintain flap vascularity. The thickness of the pedicle
limited the flap rotation to 90°.1,5 This restricted the use
of this flap in the limbs because only defects that were
in this 90° arc of rotation could be covered. In addition,
limbs have far less skin laxity in the transverse axis
when compared to the longitudinal axis.
With increasing awareness of the vascular territories
of the vessels and the location of perforators, cadaveric
and clinical studies have described a number of perfo-
rator-based flaps for soft tissue reconstruction in all
regions of the body.6,7 It is now possible to raise pedi-
cled and free perforator flaps based on a single perfo-
rator. This led to the evolution of propeller flaps that
rely on a single perforator.3,8,9 These single perforator-
based propeller flaps permit flap rotation up to 180° and
simultaneously allow linear closure of the donor defect
(Fig. 1). This ability to transfer skin from one longitu-
dinal axis to another longitudinal axis has led to the
increasing use of perforator-based propeller flaps in
limb reconstruction, especially for the lower limb.10 –17
They combine the advantages of local flaps (color and
texture match) and regional flaps (vascular pedicle is
away from zone of injury and larger size). Although
there are a large number of reports of using perforator-
based propeller flaps in lower limb reconstruction, the
application of this technique in the upper extremity is
infrequently reported.18,19 We present the results of
using perforator-based propeller flaps for upper limb
soft tissue reconstruction and suggest a treatment strat-

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 TABLE 1. Patient and Flap Data
Perforator Flap

Patient Soft Tissue Defect Flap Rotation

No Age Gender Pathology Side Location Sub-Location Size (cm) Perforator Size (cm) Shape Degrees Direction

PERFORATOR-BASED PROPELLER FLAPS

1 32 M Scar contracture R Elbow Anterior 10 ⫻ 5 Superior ulnar collateral 13 ⫻ 5.5 Ellipse 90 2
JHS 䉬 Vol A, May 

2 33 F Burn scar contracture R Elbow Anterior 10 ⫻ 5 Radial recurrent 12 ⫻ 5 Quadrilobed 90 2

3 70 F Radiation dermatitis R Distal arm Lateral 6⫻4 Radial collateral 9⫻6 Bilobed 120 3
4* 68 M Olecranon implant exposure L Elbow Posterior 4⫻4 Brachial 18 ⫻ 5.5 Ellipse 180 2
5 69 M Olecranon bursitis R Elbow Posterior 10 ⫻ 5 Radial collateral 13 ⫻ 5 Ellipse 180 2
6 54 M Olecranon bursitis R Elbow Posterior 10 ⫻ 6 Radial collateral 15 ⫻ 6 Ellipse 180 2
7 25 M Deep abrasion L Hand Palm-ulnar 8⫻4 Ulnar 8⫻4 Ellipse 120 3
8 36 M Degloving injury L Hand Palm-ulnar 8⫻3 Ulnar 12 ⫻ 3 Ellipse 160 3
9 47 M Burn scar contracture L Hand Palm-radial 6⫻3 Radial 10 ⫻ 3 Ellipse 180 2
10* 39 M Open fracture with degloving R Hand Dorso-ulnar 4⫻4 Ulnar 10 ⫻ 4 Ellipse 180 3
11 †
57 M Electrical burn defect L Hand Dorso-radial 6⫻6 Radial 17 ⫻ 6 Ellipse 180 3
12‡ 59 M Burn scar contracture L Wrist Dorso-radial 8⫻3 Radial 9⫻3 Bilobed 90 3

Patients are listed in order of location of defect.

*, case reports; †, loss of distal 20% of flap; ‡, flap donor site closure required 5 ⫻ 2 cm skin graft.

855
856 PERFORATOR-BASED PROPELLER FLAPS

FIGURE 2: A BAP-based propeller flap. A 68-year-old man (Table 1, case 4) presented with skin breakdown and implant
exposure 2 months after treatment of an olecranon fracture. A consistent Doppler signal could not be obtained for the IUCAP or
the RCAP; therefore, the BAP was located and marked (X). A An elliptical propeller flap, measuring 18.0 ⫻ 5.5 cm, based on the
BAP was then designed to cover the 4 ⫻ 4 cm defect resulting after debridement. B The flap was raised, and the pedicle was
isolated to allow 180° counter-clockwise rotation of the flap. C The donor site was closed linearly. All the wounds and the fracture
healed uneventfully.

egy based on location of soft tissue defect and perfora-
tor anatomy.
MATERIALS AND METHODS
Between April 2007 and July 2010, 10 men and 2
women with a mean age of 49 years (range, 25 to 70 y)
had upper limb soft tissue reconstruction with a perfo-
rator-based propeller flap at 3 institutions (Table 1). The
soft tissue defects resulted from release of post-burn
scar contracture in 4 patients, trauma in 3 patients,
excision of an olecranon bursa in 2 patients, and elec-
trical burns, radiation dermatitis, and debridement of an
exposed olecranon implant in 1 patient each. The pa-
rameters that were examined included the size and
location of the defect, the perforator that was used, the
size and shape of the flap, the direction (ie, clockwise or
counter-clockwise) of flap rotation, the degree of twist-
ing of the perforator, the management of the donor site
(ie, linear closure or skin grafting) and flap survival
(recorded as the percentage of the flap area that sur-
vived).
SURGICAL TECHNIQUE
Selection of perforator
The selection of an appropriate perforator is based on 2
criteria. The first criterion is the location of the perfo-
rator. The closest perforator located proximal to the
defect is preferred. This is because, in the tapering
upper limb, there is more skin available proximally.
The second criterion is the Doppler characteristics of
the selected perforator. The donor region is mapped for
audible Doppler signals that are pulsatile, loud, high
pitched, and can be consistently detected by the
probe.20 The cutaneous perforator with the most prom-
inent Doppler signal is selected as the preferred supply
for the flap and marked with a large cross. Less prom-

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 PERFORATOR-BASED PROPELLER FLAPS 857

FIGURE 3: A UAP-based propeller flap. A 39-year-old man (Table 1, case 10) sustained an open wound of the dorso-ulnar aspect
of his left hand, with divided extensor tendons to the little and ring finger and a fracture of the little finger metacarpal base.
Following debridement, the skin defect measured 8 ⫻ 4 cm. A The UAP was identified (white arrow), and a propeller flap
measuring 10 ⫻ 4 cm was designed. B The UAP (black arrow) was dissected to allow 180° clockwise rotation of the flap. C The
flap was inset, and the donor defect was closed linearly. The flap and the donor site healed uneventfully.

inent signals are marked with dots. With a little prac-
tice, one can differentiate between Doppler signals from
the main vessel versus the perforators. The sound made
by the main vessel will still be heard when the probe
goes proximal or distal, whereas the perforator is heard
only at 1 location. In addition, the sound made by the
main vessel is louder compared to the perforator. If a
prominent Doppler signal cannot be found in the terri-
tory of the selected perforator, the alternative perforator
territory is mapped.
Flap design
The location of the selected perforator denotes the pivot
point of the flap (X) (Fig. 1). The distance between the
pivot point and the distal edge of the defect is measured
(XB), and a mark is made at the same distance proximal
to the pivot point in the longitudinal axis of the limb
(XB=). The width of the defect is also measured (CD)
and marked on either side of the pivot point (C=D=), and
an elliptical flap (A=C=B=D=) is designed that will pivot
around the selected perforator (X) (Fig. 1).
Flap elevation
The initial incision is made along one lateral bor-
der of the flap. If one is undecided between 2
adjacent perforator flaps, it is better to make the
opening incision between the flaps. This will allow
dissection and assessment of the perforators of
both flaps through one incision. In the beginning, it
is preferable to do a subfascial dissection because
it is easier. As one gains confidence, a supra-
fascial dissection allows a thinner flap to be raised
and permits primary closure of the fascia. The flap
is carefully raised until the previously marked
perforators are visualized. The selected perforator
is compared visually with the adjacent minor per-

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858 PERFORATOR-BASED PROPELLER FLAPS

FIGURE 4: A RAP-based propeller flap. A 57-year-old man (Table 1, case 11) sustained a high-voltage electrical burn to his left
hand. This required a ray amputation of his small finger and resulted in a 6 ⫻ 6 cm defect over the base of the thumb metacarpal.
A An elliptical propeller flap, measuring 17 ⫻ 6 cm, based on the RAP (X) was designed to cover the defect. B The flap was
raised, and the pedicle was isolated to allow 180° clockwise rotation of the flap. C We lost the distal 20% of the flap (yellow
dotted line) due to venous congestion, and D an abdominal flap was done for coverage of the residual defect.

forators. If another perforator appears larger, or 2
perforators are of the same size, an intraoperative
Doppler assessment of the perforators is done. If
the Doppler signals also sound similar, the perfo-
rator closer to the defect is selected. The flap
design might have to be modified based on the
location of the selected perforator. The flap is
incised like an island, and all other perforators are
ligated.
Flap rotation and inset
The extent of dissection of the perforator depends
on the degree of flap rotation required. One has to
balance the risk of greater perforator dissection
with the benefit of greater flap mobility. The per-
forator is dissected to the point at which the flap
can be rotated easily into the defect by carefully
dividing any fibrous strands along the pedicle that
impede this rotation. In flaps that need to rotate
180°, it is a good idea to see which rotation (clock-
wise or counter-clockwise) results in a greater
twisting or kinking of the pedicle and choose the
appropriate direction of rotation.21 If the flap is
raised under tourniquet control, it is imperative to
achieve excellent hemostasis, using bipolar cau-
tery when the flap is raised. This will allow partial
closure of the donor defect before the tourniquet is
released. Linear closure of the donor defect can
become challenging after the tourniquet is released
due to the post-tourniquet edema. We prefer to
rotate the flap into the defect only after the tour-
niquet has been released and the flap is perfusing
in its native position for 5 to 10 minutes.
Postoperative care
All patients are splinted for 1 week with advice to keep
the limb elevated. They are started on range of motion
exercises at 1 week. The sutures are removed at 2
weeks, and patients are allowed to resume normal ac-
tivity.
RESULTS
The mean defect size was 7.5 ⫻ 4.3 cm (range, 4 ⫻ 4
cm to 10 ⫻ 6 cm) (Table 1). Six defects were located
around the elbow, and 6 were located around the wrist
and hand. We used 6 different perforators for our pro-
peller flaps. Three propeller flaps each were based on
the radial collateral artery perforator (RCAP), ulnar
artery perforator (UAP), and radial artery perforator
(RAP) respectively. One flap each was based on the
radial recurrent artery perforator (RRAP), brachial ar-
tery perforator (BAP), and superior ulnar collateral ar-
tery perforator (SUCAP). Figures 2, 3, and 4 depict
representative examples of the flaps used in this series.
The flaps were designed as ellipses in 9 cases, bilobed
in 2 cases, and quadrilobed in 1 case. The smallest flap

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 PERFORATOR-BASED PROPELLER FLAPS 859

TABLE 2. Details of Upper Limb Perforator-Based Propeller Flaps

Perforator Details Flap Details

No. Main Vessel Location of Distal Major Perforator Axis Size (cm)

1 Inferior ulnar collateral artery5,23,24 2–4 cm proximal to medial epicondyle Medial intermuscular septum* 12 ⫻ 6
2 Superior ulnar collateral artery5,25,26 8–10 cm proximal to medial Anterior to medial 14 ⫻ 6
epicondyle intermuscular septum
3 Brachial artery5,42,43 8–10 cm proximal to medial Posterior to medial 18 ⫻ 6
epicondyle intermuscular septum
4 Radial recurrent artery5,44–46 1–3 cm proximal to lateral epicondyle Lateral intermuscular septum† 12 ⫻ 6
5 Radial collateral artery 5,25,47–49
5–7 cm proximal to lateral epicondyle Lateral intermuscular septum 16 ⫻ 6
6 Ulnar artery5,33–35 4–6 cm proximal to pisiform Ulnar styloid and medial 12 ⫻ 4
epicondyle
7 Radial artery5,28–32 1–3 cm proximal to radial styloid Radial styloid and lateral 12 ⫻ 4
epicondyle

*, line joining medial epicondyle and posterior axillary line; †, line joining lateral epicondyle and deltoid insertion.

measured 8 ⫻ 4 cm and the largest flap measured
18.0 ⫻ 5.5 cm. The average flap size was 12.2 ⫻ 4.7
cm. It was possible to linearly close the donor site in all
cases except case 12 (Table 1). Although the flap width
was only 3 cm, the surrounding post-burn scar made it
impossible to close the linear flap donor site. In one
patient (Table 1, case 11), we lost the distal 20% of the
flap (Fig. 4C). This was our first case of a perforator-
based propeller flap, and we did not isolate the pedicle
sufficiently to allow a 180° flap rotation. This patient
required an abdominal flap for coverage of the residual
defect (Fig. 4D). The remaining 11 flaps survived com-
pletely. There were no other postoperative complica-
tions. All the patients returned to their previous occu-
pations, and all were satisfied with the aesthetic
outcome.
DISCUSSION
Many options are available for the reconstruction
of small- to medium-sized soft tissue defects of the
upper extremity. These include pedicled local, re-
gional, and distant flaps, and free flaps. Pedicled
local flaps (transposition or rotation) are simple to
do and bring skin with a good color and texture
match. However, their arc of rotation is restricted
to 90°, and their utility is limited to areas of skin
laxity. Pedicled regional flaps (radial and ulnar
artery forearm flaps and posterior interosseous ar-
tery flaps) have all the advantages of local flaps
and also have a greater arc of rotation. However,
they require considerable dissection, division of a
major vessel, and possibly a skin graft for the
donor defect. Pedicled distant flaps (abdominal
and groin flaps) have mostly been reserved for
larger defects and for cases that have failed other
reconstructive options. They provide a safe and
reliable alternative, but the tissue match is poor,
and the immobilization required can result in sub-
stantial stiffness. Free skin flaps are a good option
for small- to medium-sized defects. They bring
tissue away from the zone of injury. However, they
require microsurgical anastomoses with a potential
risk of total flap loss. The color and texture match
is poorer when compared to a local flap. A perfo-
rator-based propeller flap for the upper limb com-
bines the advantages of pedicled local flaps (good
tissue match), pedicled regional flap (180° arc of
rotation), pedicled distant flap (reliable), and free
flap (tissue away from zone of injury). In addition,
in most cases, it allows linear closure of the donor
defect.11 This is made possible by the propeller
design of the flap, which on rotation brings the
bridge segment of the flap into the widest portion
of the donor defect, making closure easier
(Fig. 1).
The major drawback of a perforator-based propeller
flap is that the perforator must be intentionally twisted
to allow the flap to rotate. The standard teaching in flap
surgery is to avoid twisting of the flap pedicle to prevent
vessel kinking and occlusion. This is particularly im-
portant for veins, which are a low-pressure system.
These safety concerns have prevented widespread
adoption of this technique. Five previous experimental
studies have studied the effect of pedicle twisting on

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860 PERFORATOR-BASED PROPELLER FLAPS

FIGURE 5: Location of perforators and their vascular territory. A Anterior view. B Posterior view. The major distal perforator is
shown with a cross (X) overlying the main vessel. The area predominantly perfused by this perforator has been depicted as an
elliptical zone having the same color as the perforator.

flap survival.22–26 Based on these studies and reports in
the literature, perforator-based propeller flaps with a
rotation up to 180° have shown to be viable and versa-
tile.2,3,8,9,21,27 In patients needing 180° of flap rotation,
we attempt flap rotation in both a clockwise and coun-
ter-clockwise fashion. The rotation that results in less
pedicle twisting is selected.21 This is done before re-
lease of the tourniquet. When a rotation has been se-
lected, we put the flap back in its native position. The
actual rotation is performed after release of the tourni-
quet. We believe that an empty vessel is more suscep-
tible to kinking compared to a vessel with flow. It is
also important to isolate the pedicle and obtain as much
length as is safely possible when a 180° rotation is
planned.
Saint-Cyr et al have mapped out the territory per-
fused by a single perforator by carrying out static and
dynamic dye injection studies in fresh cadavers.28 They
studied the radial artery, ulnar artery, and dorsal meta-
carpal artery perforator flaps in the upper limb. They
introduced the concept of a perforasome (unique vas-
cular territory supplied by a single perforator) and de-
termined that the vascular axis of perforator flaps
should follow the axial alignment of the linking vessels,
which in turn follows the axial anatomy of the limb.
Linking vessels are vessels connecting 2 adjacent per-
forasomes. It is believed that these linking vessels are
usually in a collapsed state. When a perforator-based
propeller flap that includes 2 perforasomes is raised on
a single perforator, the linking vessels open up, allow-
ing perfusion of both territories from a single perforator.
This is similar to the choke vessel concept proposed by
Taylor et al, in which choke vessels connect 2 adjacent
angiosomes.29
It is important not to confuse the vascular ter-
ritory of the main vessel with the vascular territory
of a single perforator. Although a few cadaveric
studies show the static area perfused by a single
perforator,30 –34 most studies inject the main vessel
from which the perforator arises and, therefore,
determine the territory of the main vessel and all of
its perforators. In the living individual, the opening
of previously collapsed vascular (choke) channels
invariably allows perfusion of a larger skin terri-

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 PERFORATOR-BASED PROPELLER FLAPS 861

FIGURE 6: The arc of rotation of perforator-based propeller flaps. A Anterior view. B Posterior view.

tory by a single perforator. To our knowledge, the
exact dynamic territory perfused by a single per-
forator in vivo is unknown. Until the exact territo-
ries can be determined, it is best to raise flaps that
fall within the static territories. We used past clin-
ical and anatomical studies of upper limb perfora-
tor flaps and our clinical experience to determine
the size of our perforator-based propeller flaps. We
suggest these flaps only for small- to medium-
sized defects of the upper limb.
The upper limb has more than 100 cutaneous perfo-
rators (⬎0.5 mm diameter).6,7 Chen et al divided the
skin of the upper extremity into 16 vascular territories
based on the deep trunk vessels from which these per-
forators arise.7 A perforator-based propeller flap can be
designed on any perforator, and a number of articles
present the usefulness of individual perforator-based
flaps for upper limb reconstruction.18,19,30,35– 48 The
elbow, wrist, and hand represent the 3 areas in the upper
limb that usually require flap reconstruction. The per-
forator flaps available for elbow reconstruction include
5 flaps: (1) inferior ulnar collateral artery perforator flap
(IUCAP),6,37,38 (2) SUCAP,6,39,40 (3) BAP,6,49,50 (4)
RRAP,6,51–53 and (5) RCAP.6,39,54 –56 Two perforator
flaps are available for wrist and hand reconstruction:
RAP6,30,42– 45 and UAP.6,46 – 48
The details (main vessel, location of distal per-
forator, longitudinal axis, and size) of the flaps
have been summarized in Table 2. Figure 5 depicts
the location of the distal perforator in relation to
the main vessel and the approximate vascular ter-
ritory of a flap that could be raised on this perfo-
rator. Figure 6 depicts the arc of rotation of per-
forator-based propeller flaps. The cutaneous
perforators of the inferior ulnar collateral artery,
superior ulnar collateral artery, and brachial artery
arise in the region of medial intermuscular sep-
tum.37– 40 Propeller flaps based on the SUCAP are
designed anterior to the medial intermuscular sep-
tum, whereas the propeller flap based on the BAP
is designed posterior to the medial intermuscular
septum. The cutaneous perforators of the recurrent
radial artery and radial collateral artery arise in
relation to the lateral intermuscular septum.39,51–56
The maximum flap width that can be closed lin-
early in these 5 flaps (IUCAP, SUCAP, BAP,

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862 PERFORATOR-BASED PROPELLER FLAPS
TABLE 3. Algorithm for Selection of Appropriate Perforator-Based Propeller Flap
Location of Soft Tissue Defect
Anatomical Location Sub-Location
Elbow Anterior
Medial
Posterior
Lateral
Wrist and hand Ulnar
Radial
RRAP, and RCAP) raised in the arm is 6 cm,
whereas it is 4 cm for the flaps raised over the
forearm (UAP and RAP). Table 3 summarizes the
selection of appropriate perforator-based propeller
flaps for soft tissue defects of the elbow, hand, and
wrist. For anterior, medial, and posterior elbow
defects, it is preferable to use perforator flaps from
the medial aspect of the arm (IUCAP, BAP, and
SUCAP) because the donor site scar is hidden, and
the skin is hairless and more pliable. Between
these 3 flaps, the IUCAP-based propeller flap is
most suitable for elbow reconstruction because the
perforator (and, hence, the pivot point) would be
located closest to the defect. For a lateral elbow
defect, the choice is between the RRAP and the
RCAP flaps. The RCAP-based propeller flap is a
better choice because the RRAP flap is rather thick
and has a smaller vascular territory.6,7 Choosing
between the UAP and RAP flaps is simple. Radial-
sided wrist and hand defects are covered with a
RAP flap, whereas ulnar defects are covered by the
UAP flap.
A perforator-based propeller flap is designed in the
long axis of the limb because there is greater skin laxity
in the long axis when compared to the transverse axis.
In addition, flaps designed along the long axis include
the linking vessels (that follow the axis of the limb).
The flap is designed on the perforator proximal to a
defect over the elbow, wrist, or hand because the taper-
ing nature of the upper limb means that more skin is
available proximally. Although perforator-based pro-
peller flaps can be planned with high flexibility and
designed wherever perforators exist, we believe that the
most effective treatment strategy in upper extremity
reconstruction using these flaps is to design flaps in the
JHS 䉬 Vol A, May 
Choice of Perforator
Appropriate Alternate
Inferior ulnar collateral artery Superior ulnar collateral artery
Radial recurrent artery
Inferior ulnar collateral artery Superior ulnar collateral artery
Brachial artery
Inferior ulnar collateral artery Brachial artery
Radial collateral artery
Radial collateral artery
Ulnar artery
Radial artery
long axis of the limb based on the closest perforators
proximal to the defect.
REFERENCES
1. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method.
Br J Plast Surg 1991;44:53–54.
2. Katsaros J. Use of the island tensor fasciae latae flap to cover a
chest-wall defect. Plast Reconstr Surg 1982;69:1007–1009.
3. Teo TC. The propeller flap concept. Clin Plast Surg 2010;37:615–
626.
4. Murakami M, Hyakusoku H, Ogawa R. The multilobed propeller
flap method. Plast Reconstr Surg 2005;116:599 – 604.
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